| NPI | 1225698822 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: AZ LPT30714) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ LPT-030714) | 
| Enumeration Date | 2019-06-17 | 
| Last Update Date | 2025-06-10 |